GW1--01943_Well Construction - GW1_20240325

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane .•14..WATERZONES - . -t - - ,
Well Contractor Name FROM TO DESCRIPTION
30 7 3-A ft. ft. 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER'CASING(for multi-cased wells)OR LINER(if np livable)
Crane Bros Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 104 ft- 6.25 ! in* SDR-21 PVC
Company Name 2.Well Construction Permit'-` 217722-p 16.INNER R CASING OR TUIII 7G(eothcr'mal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UUC.County.State,Variance,etc.) rt. rt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply 17.SCREEN - .
PP's Well: FROM TO DIAMETER SLOT SIZE THICKNESS f MATERIAL
❑Asrtcultural ❑Municipal/Public ft. ft. in. 1,
UGeothermal(Heating/Cooling Supply) ItResidential Water Supply(single) rt. n in. ij
❑industrial/Cotnmercial ❑Residential Water Supply(shared) is..GROUT . -' - -
flhrigatinn flWellc>100,000GPI) _FROM___..TO_____MATERIAL ____I EMPLACF.MENTMETHOD&AMOUNT •
Non-Water Supply Well: ' 0 ft. 20 ft. benonite pumped -'-I
❑Monitoring ❑Retxivery ft. .ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) !
❑Aquifer Storage and Recovery ❑Salinity-Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test UStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG(attach additional sheets if necessary)__ - - .
FROM TO DESCRIPTION(color•hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 104 ft. clay
•
4.Date Well(s)Completed: 11/30/2023 Well W# 104 ft• 930 ft• granite
$a.Well Location: fa ft.
Dan Sieg _ _ ft. ft.
facility/Owner Name Fatuity ID#(if applicable)- ft. f.. �, ^,
433-Wooten-Rd., NC 28734 ft. e q ,1-'''t 'V is;�j7
Physical Address,City,and Zip �+ r��y ft ft. MAR i '"rC i
*Macon 6593 f 64470 21.REMARKS. _ - lT U
i
lllIto+IIPe:: 1T1 i'r,,
County Panel Identification No.(PiN) ,, +K'� .'y t.�7?l
L.rC'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one rat long is sufficient) 22.Certification:
35.08.7'E 0 N 83 21.488 w tl4, C-Z.-e---! N/13/2024
6.Is(are)the well(s): !Permanent or ❑Temporary Signature of Certified Well Contractor Date
B,ysigning this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair-to an existing well: ❑Yes or L'JNo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this L a repo?,Jill ow kttaini well[stash asviuti itOrinatirM aiid et lain the nature oldie of this record has been provided to the well owner.
repair under#21 remarlr•section or on the back of this forest.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sim Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 930 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
200 24a. For Ail Wells: Original form to Division of Water Resources (DWR),
(rt
10.Static water level below top of casing: d •) Information-Processing Unit,1617 MSC,Raleigh,NC27699-1617
If water level is above casing.use"+" I
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 0'25 (fn.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised.6-6-2018.